Emergency Preparedness Checklist and Tips

An emergency can happen at a moment’s notice. Act now and prepare before disaster strikes! This checklist will help you get started.

You’re not prepared if you cannot check these items on your emergency plan: My dialysis facility has the current street address and phone number(s) that they need to contact me and/or household member(s) or care partner(s).

I have discussed my emergency plan and my dialysis facility with my household members. Dialysis facility name: _________________________________________________

Dialysis facility address: _______________________________________________

Dialysis facility telephone number: ______________________________________

I have a back-up plan to get care if my dialysis facility is closed. Alternative dialysis facility: _____________________________________________

Alternative dialysis facility address: ______________________________________

Alternative dialysis facility telephone number: ____________________________

I have a copy of my current treatment prescription record. Current Dialysis PrescriptionTime on treatment: ______________________

Blood flow rate: ________________________

Dialysate flow rate: ______________________

Dialysate: __________________________

Treatment anticoagulation medication: _________________________

I have an additional medical condition:_______________________________________________

I check the items in my emergency kit every six months to ensure they have not expired and are working properly.

I review and update my emergency list at least every six months.

Use this list to help you build your emergency kit: � Prescription medications and list of medications � Insurance and/or Medicare Card � Current copy of monthly lab report � First aid kit � Bottled water � Renal diet friendly non-perishable food � Cash � Spare glasses � Manual can opener

� Warm blanket � Battery-powered radio � Flashlight with extra batteries � Cell phone with charger � Books, games, puzzles � Contact list of healthcare members � Picture ID � Car tank full of gas/alternative

transportation

Discuss your emergency plans with your household members and care team.

Patient Assistance Hotlines ARA: 888.880.6867 DaVita: 800.400.8331 DCI: 866.424.1990 Fresenius: 800.626.1297 US Renal Care: 866.671.8772

ESRD Network:______________________________ This material was prepared by the Kidney Community Emergency Response (KCER) contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMS Contract #: HHSM-500-2016-00007C Publication Number: FL-KCER-7K2T3C-07252018-01.

Emergency Preparedness Checklist and TipsAn emergency can happen at a moment’s notice.

Act now and prepare before disaster strikes!

This checklist will help you get started.

You’re not prepared if you cannot check these items on your plan:

My dialysis facility has the current street address and phone number(s) needed to contact me and/or household member(s) or care partner(s).

I have discussed my emergency plan and my dialysis facility with my household members. Dialysis facility name: ________________________________________Dialysis facility address: ______________________________________Dialysis facility telephone number: ______________________________

I have a back-up plan to get care if my dialysis facility is closed. Alternative dialysis facility: ____________________________________Alternative dialysis facility address: _____________________________Alternative dialysis facility telephone number: _____________________

I have a copy of my current treatment prescription record.

I check the items in my emergency kit every six months to ensure they have not expired and are working properly.

I review and update my emergency list at least every six months. Use this list to help you build your emergency kit:

• Prescription medications andlist of medications

• Insurance and/or Medicare card• Current copy of monthly lab report• First aid kit• Bottled water• Renal diet friendly

non-perishable food• Cash• Spare glasses

• Manual can opener• Warm blanket• Battery-powered radio• Flashlight with extra batteries• Cell phone with charger• Books, games, puzzles• Contact list of healthcare members• Picture ID• Car tank full of gas/alternative

transportation

Patient Assistance HotlinesARA: 888.880.6867 DaVita: 800.400.8331 DCI: 866.424.1990 Fresenius: 800.626.1297 US Renal Care: 866.671.8772

ESRD Network: _________________________

This material was prepared by the Kidney Community Emergency Response (KCER) contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMS Contract #: HHSM-500-2016-00007C Publication Number: FL-

KCER-7K2T3C-07252018-01.